Healthcare from the perspective of a clinician encompassing both the capture of the clinical viewpoint as well as the technology to help clinicians capture knowledge at the point of care
The thoughts expressed are my own and do not necessarily represent those of Nuance

Talking is the best user interface...Language is natural to people and universal to all cultures. Language is a spoken medium. Written language is merely the symbolic representation of spoken language. It's an abstraction, but a necessary one.

And he asked But is the technology there yet?. You bet!

In the future, we'll talk to our computers and they'll talk back. We know this is true because talking is the most natural way for human beings to communicate. The evolution of the human-machine interface always moves the workload of interaction from the person to the computer. The perfect UI would be a natural conversation, just like you have with other people.

Could not have said it better myself! This is especially true in the healthcare setting where clinicians are overwhelmed with paper work and documentation requirements. As Mike points out there are hurdles, no insurmountable

Technology: creation of software (supported by powerful hardware) that can understand spoken language

Technology: content must be searchable. Text can be indexed, and we've grown addicted to the ability to search for and find the things we've written, and

Cultural: the barrier to voice-based computer interaction is one of habit. We've grown used to typing on keyboards. Although speaking is natural, speaking to a computer feels a little weird at first. And people generally don't like learning a new way to do things.

In the piece he features three products that address these issues and go much farther VoiceBase for indexing and searching, DialtoDo to convert spoken utterances into action, and as he puts it the Mother of All Voice Applications, Dragon NaturallySpeaking 11 from Nuance.

Dragon NaturallySpeaking takes dictation so accurately that it begins to approach Steve Jobs' favorite word: "Magical." For the first week of use, I was actually shocked when it correctly recognized obscure names, extremely technical terms, brand names with correct capitalization (for example, iPhone) and performed other unlikely feats. Since I started using it, I've written the first drafts of all of my columns and blog posts, including this column, using Dragon NaturallySpeaking.

But as Mike points out the downside to this innovations, speed and accuracy that is especially relevant to healthcare is the lack of time to think. Many of us use typing time as thinking time....if you lose the typing time you lose the thinking time and generating content becomes a little more challenging at first:

The accuracy has an unexpected and very welcome side effect: It makes it easier to write. I assumed that typing was automatic, requiring little brain power. But using Dragon has demonstrated that mental energy was diverted from the task of typing to the task of thinking, which is what makes writing so much easier. I can also write faster using Dragon.

This requires a change in behavior and an adaptation to the lost thinking time that can make clinicians feel less productive as they have to pause during dictations. But for those that already adapted to dictation and that process is easy (think existing dictating clinicians who use a telephone or hand held recorder device to dictate and generate clinical notes using traditional dictation and transcription) then a move to dictating directly to your PC is one step closer.

But be warned as he identified "It's not feasible yet for most people to completely abandon keyboards, mice and text and interact entirely via the spoken word." - so don't try to make that happen or expect it to happen. Again think of the telephone and texting - in some respects Texting could be considered a retrograde step but for many (read millions) texting is preferable to actually using the phone to speak to someone.

And what can I say about Dragon NaturallySpeaking 11? It's the biggest user interface advance since the iPhone. The bottom line is that voice is finally ready for prime time. I've decided to continue my experiment indefinitely and to keep pushing the voice envelope as far as it will go. Voice makes using a computer faster, easier and a lot more fun.

How about you - have you made the jump? Can it work for you in your environment and if not what is is the barrier to using voice in your world?

As always the data requires careful analysis and while superficially linking taking fish oil to reducing cardiac diseases but there are problems with this approach

- the study was arrows out on patients with Cardiomyopathy

- study is preliminary and yet to be reviewed and published in a peer review journal

While taking fish oil may not cause harm (apart from your wallet) linking this abstract for the purpose of selling more fish oil is a major part of the misleading activities that take place to confuse the general public and persuade them to buy unnecessary alternative therapies.

In yet another noteAble challenge faced in the healthcare system over the coming years is the massive increase in Dementia over the next 20 years. Expect to see an additional 85% more in the next 20 years

An elderly man died in hospital after waiting five hours to see a doctor. After being told how Roland Holbrow died without seeing a doctor, a coroner yesterday criticized European rules that restricting junior medics' working hours.
Michael Rose described the European Working Time Directive....'Hospitals are running into problems,' he said. 'I can see the clear warning signs, although I am not going to refer this to Mr Lansley as I think he will already be aware of it.

There's no shortage of views from both sides of this discussion:

Those in favor of restricting hours

..I don't agree that anyone should work that amount of hours, its not safe, and it courses problems in the future.
..criticise the PCT for not employing enough Doctors.
..Hospitals at fault here for NOT recruiting sufficient staff to provide proper shift cover... instead, they've been reducing manning levels instead so as not to exceed the WTD hours limit
..At the end of the day though do we really want to be treated by a doctor who has been on duty for over 12 hours. Pilots and the like are restricted on hours worked for safety reasons so should we really be seeing a doctor who is dead on his/her feet and then expect them to make the correct diagnosis first time every time. I doubt if many hospital administrators have a clue what happens overnite in their hospital and how bad things are they will have left by 5 30 in any case

And those that think we need to return to longer hours so junior doctors get "more experience"

..Good to see such a courageous coroner and Clinical Director, both willing to speak unpopular truths. We must unshackle Juniors from the restrictions of the "New Deal", and EWTD, whilst maintaining a sensible work / not work life balance. Also we need a 24/7 365 days a year fully active acute sector i.e. more flexible working all round, and likely more doctors
..can some one explain to me why FY1's were taken off doing night shifts and regular weekends? It seems ridiculous that we have a national shortage of doctors yet a massively under used resource of Dr's needing exposure so as to mature into decision making
..A few facts about EWTD. 1. It was never intended for the professions. I know of no professional (or other successful person in other walks of life) who has worked ONLY 48hrs pw when 'on the way up' (or indeed having 'arrived'!)

The College and others have consistently argued that junior doctors need to work more than the 48 hours per week permitted by the European Working Time Directive in order to amass enough experience and learning to become safe and competent surgeons.

nearly 60 percent of respondents said they had worked while sick at least once and nearly a third reported having worked while sick more than once. At one "outlier" hospital not named in the study, 100 percent of the respondents reported having reported to work while sick.
A related problem, the survey found, is that busy medical residents (who are already known to not get enough sleep in the early years of post-medical school training, despite rules attempting to ensure they do) also reported not having enough time to see a doctor for their own medical care.

One thing is for sure - tired people are not giving their best. As one junior doctor put it

In the last 2 weeks I have worked 105 hours without a day off. This is my rota and includes no overtime. I would say my patient care was compromised at the end as was my love for the job. ....I have maximum 2 hours of teaching every other week as the wards are too busy to leave the rest of the time

Managing the hours and providing a good working environment is going to be essential. Technology will play a role in helping reduce work burdens and creating efficiencies but updating our training system must be included in the update to our health systems

50 years on much of her insistence on scientific rigor and data remain the main stay of drug review and our process for managing new drugs and procedures. INteresting for someone who got the job because her name sounded like a man's

She was hired sight unseen by Dr. Eugene Geiling, a renowned pharmacology professor at theUniversity of Chicago, because he read her name as Francis. When she got the acceptance letter, in 1936, she realized his mistake and asked a professor at McGill University whether she could accept the job.

Not sure things have changed as much as we might like given the intense focus currently on Women's Equality Day on inequality on women's opportunities and pay

Dr. Kelsey demanded better tests for thalidomide. She also distrusted Merrell, a company that had a history of confrontations with the F.D.A. She soon discovered that Kevadon had been linked in Europe with reports of nerve damage — reports the company had failed to provide her.

“I had the feeling throughout the day,” she wrote after a meeting with company executives, “that they were at no time being wholly frank with me and that this attitude has obtained in all our conferences, etc., regarding this drug.”

Again - not sure things have changed much and we must continue to demand science and data to support treatments

imagine the possibilities for grafts, artificial organs and joints built customized to the individual. We are starting to see customized drugs - it won't be long before we see customized implants and even artificial organs.

Tuesday, September 7, 2010

I'm what is probably no big surprise we find detailed studies showing billions wasted with unnecessary vista to the doctor and the ED: Health Care Wastefulness Is Detailed in Studies

A heavy reliance on emergency rooms care is seen as a sign of weaknesses in the primary health care system. http://nyti.ms/cFqcED

If there's a lesson here it's the fixing of the healthcare system involves everyone of us. Making good choices, intelligent use of resources and an acceptance that things are going to change in the way we decide on care, who receives what and when Are you playing your part

Friday, September 3, 2010

The latest in a an annual competition looking for unusual and innovative users of Dragon the winner of the 2010 I speak Dragon contest EvanUp posted a story Dragon NaturallySpeaking: a matchmaker - a truly heart warming story of adversity that was overcome by chance introduction linked to Dragon and culminated in marriage......EvanUp the author was diagnosed with MS

After a few strange experiences with blurred vision and numbness, I was diagnosed with multiple sclerosis and was absolutely terrified by what it might do to me.

His local administrator suggested he try Dragon and pointed him to another user who told him without any hesitation or reservation matter-of-factly:

“I have MS. It started affecting my hands so I got Dragon. It saved my career. Why do you ask?"

Sharing a common bond and enemy the two formed a friendship that culminated in marriage and as EvanUp puts it:

Dragon NaturallySpeaking and multiple sclerosis served as our extremely unlikely matchmakers, and the luckiest break I've ever had

In what is important in life this ranks up at the top on my list and aside from congratulating EvanUp for winning the competition I want to thank him for sharing his quite personal but truly positive outlook on life in the shadow of adversity.

Wednesday, September 1, 2010

In a recent online discussion the question was posed "what makes up the skills and requirements of a CMIO". There was much discussion on the nature of the job, the skills needed and where new recruits needed to go to get those skills. But one reply stood out linking the skill set to everything we learn and do as clincinas. So with the permission of of a W Joseph Ketcherside MD, CEO of the Ketcherside Group and a Clinical informaticist who also practices of clinical medicine I post his response in it's entirety

Our patient (a health care system) comes to us with a Chief Complaint (I want to install an EMR).

We gather a little more specific information by taking a History of Present Illness (Why do you want to install an EMR? Improved safety? Decrease cost? Improve quality? Integrate inpatient and outpatient care? And so on.)

We take some Past Medical History (What systems have you worked with before? Any successful implementations? Failed ones?)

We do the ROS (How do you sit in the market? Market share? Referral areas and types? What are the financials? What is the culture overall?

What academic relationships do you have? What is your system's relationship to the community? And so on.)

Then, we do the Physical Exam (Current state analysis and documentation. Palpate the database. Auscultate the medical staff.)

We develop a Differential Diagnosis (Major processes that could be impacted and possible solutions.)

We work with the patient (health system) to determine what a good health outcome would be for them (Future state model).

We come to agreement on a treatment plan (Implementation roadmap and project plans) that will reach that future state.

So, I still practice medicine. When I was a neurosurgeon I cared for multi-system organisms (people).

As a clinical informaticist, my patients are multi-organism systems. But, they are still my patients.

And, sitting in the ED on a Saturday night of a CPOE go-live, I would observe that CPOE implementation is exactly like clipping an aneurysm - hours and hours of boredom randomly interspersed with moments of stark terror.

So that's my two cents on the practice of Applied Clinical Informatics.

This resonates with me and is close to the points I made in a guest posting over at Healthcare
IT Today "A Day in the Life of a CMIO. WHat's your experience - what makes a good healthcare informaticist?
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